Veterans' experiences of moral injury, treatment and recommendations for future support.

INTRODUCTION: Moral injury (MI) significantly impacts the lives of many UK military veterans however, there is a lack of manualised treatment to address the needs of this population. To develop future treatments that are acceptable and well tolerated, veterans should be consulted on their experiences of existing psychological treatments and suggestions for future treatments. METHODS: 10 UK military veterans were interviewed about their experiences of receiving treatment for psychological difficulties after MI, and beliefs about core components of future treatments. Thematic analysis of these interviews were conducted. RESULTS: 2 superordinate themes were identified: experiences of previous mental health treatment and perceptions of the proposed treatments. Reflections on cognitive behavioural therapy were mixed, with some describing that it did not ameliorate their guilt or shame. In future treatments, focusing on values, using written letters and including therapy sessions with close companions were considered beneficial. Veterans reported that a strong rapport with therapist was key for MI treatment. CONCLUSION: Findings provide a useful account of how current post-trauma treatments may be experienced by patients with MI. Although limited by sample size, the results highlight therapeutic approaches that may be helpful in future and provide important considerations for therapists treating MI.

Adversity during military service: the impact of military sexual trauma, emotional bullying and physical assault on the mental health and well-being of women veterans.

INTRODUCTION: Despite making up about 11% of the UK military, there remains limited investigation on the impact of adversity women experience during their service in the UK military. Military adversity can result in a range of well-being difficulties that may persist following transition out of military. The present study therefore examined the prevalence and correlates of different types of military adversity (defined as sexual harassment, sexual assault, emotional bullying and physical assault) within a community sample of UK women veterans. METHODS: Participants were recruited from a UK charity supporting women veterans. 750 women veterans completed an online survey collecting information on sociodemographic and military factors, military adversity, as well as mental health and well-being difficulties. Associations between variables were explored using multivariate logistic regressions. RESULTS: The findings indicate a high prevalence of military adversity (22.5% sexual harassment, 5.1% sexual assault, 22.7% emotional bullying and 3.3% physical assault). Younger women, those who held an officer rank during service and those who reported having a combat or combat support role during service were most at risk of military adversity. All types of adversity were significantly associated with probable post-traumatic stress disorder. Sexual harassment was additionally significantly associated with physical somatisation; sexual assault with alcohol difficulties; and emotional bullying with common mental health difficulties, low social support and loneliness. CONCLUSIONS: This study indicates that UK women veterans are at risk of a range of adverse experiences during military service and provides evidence of the impact of such adversities on mental health and well-being. Further research is required to better understand these relationships.

Effectiveness of treatments for symptoms of post-trauma related guilt, shame and anger in military and civilian populations: a systematic review.

INTRODUCTION: Individuals who have been exposed to a traumatic event can develop profound feelings of guilt, shame and anger. Yet, studies of treatments for post-traumatic stress disorder (PTSD) have largely investigated changes in PTSD symptoms relating to a sense of ongoing fear or threat and the effectiveness of such treatments for post-trauma related guilt, shame or anger symptom reduction is comparatively not well understood. METHODS: This review systematically examined the effectiveness of existing treatment approaches for three symptoms associated with exposure to traumatic events: guilt, shame and anger. Studies included had to be published after 2010 with a sample size of n=50 or greater to ensure stable treatment outcome estimates. RESULTS: 15 studies were included, consisting of both civilian and (ex-) military population samples exposed to a wide range of traumatic events (eg, combat-related, sexual abuse). Findings indicated a moderate strength of evidence that both cognitive-based and exposure-based treatments are similarly effective in reducing symptoms. Cognitive-based treatments were found to effectively reduce post-trauma related guilt and anger, while exposure-based treatments appeared effective for post-trauma related guilt, shame and anger. CONCLUSIONS: The findings suggest the importance of confronting and discussing the traumatic event during therapy, rather than using less directive treatments (eg, supportive counselling).Nonetheless, while these results are promising, firm conclusions regarding the comparative effectiveness and long-term impact of these treatments could not be drawn due to insufficient evidence. Further empirical research is needed to examine populations exposed to traumatic events and investigate which treatment approaches (or combination thereof) are more effective in the long-term.

Addressing moral injury in the military.

Moral injury is a relatively new, but increasingly studied, construct in the field of mental health, particularly in relation to current and ex-serving military personnel. Moral injury refers to the enduring psychosocial, spiritual or ethical harms that can result from exposure to high-stakes events that strongly clash with one's moral beliefs. There is a pressing need for further research to advance understanding of the nature of moral injury; its relationship to mental disorders such as posttraumatic stress disorder and depression; triggering events and underpinning mechanisms; and prevalence, prevention and treatment. In the meantime, military leaders have an immediate need for guidance on how moral injury should be addressed and, where possible, prevented. Such guidance should be theoretically sound, evidence-informed and ethically responsible. Further, the implementation of any practice change based on the guidance should contribute to the advancement of science through robust evaluation. This paper draws together current research on moral injury, best-practice approaches in the adjacent field of psychological resilience, and principles of effective implementation and evaluation. This research is combined with the military and veteran mental health expertise of the authors to provide guidance on the design, implementation and evaluation of moral injury interventions in the military. The paper discusses relevant training in military ethical practice, as well as the key roles leaders have in creating cohesive teams and having frank discussions about the moral and ethical challenges that military personnel face.

Mental health of staff working in intensive care during Covid-19.

BACKGROUND: Staff working in intensive care units (ICUs) have faced significant challenges during the COVID-19 pandemic which have the potential to adversely affect their mental health. AIMS: To identify the rates of probable mental health disorder in staff working in ICUs in nine English hospitals during June and July 2020. METHODS: An anonymized brief web-based survey comprising standardized questionnaires examining depression, anxiety symptoms, symptoms of post-traumatic stress disorder (PTSD), well-being and alcohol use was administered to staff. RESULTS: Seven hundred and nine participants completed the surveys comprising 291 (41%) doctors, 344 (49%) nurses and 74 (10%) other healthcare staff. Over half (59%) reported good well-being; however, 45% met the threshold for probable clinical significance on at least one of the following measures: severe depression (6%), PTSD (40%), severe anxiety (11%) or problem drinking (7%). Thirteen per cent of respondents reported frequent thoughts of being better off dead, or of hurting themselves in the past 2 weeks. Within the sample used in this study, we found that doctors reported better mental health than nurses across a range of measures. CONCLUSIONS: We found substantial rates of probable mental health disorders, and thoughts of self-harm, amongst ICU staff; these difficulties were especially prevalent in nurses. Whilst further work is needed to better understand the real level of clinical need amongst ICU staff, these results indicate the need for a national strategy to protect the mental health, and decrease the risk of functional impairment, of ICU staff whilst they carry out their essential work during COVID-19.

The impact of military service on health and well-being.

BACKGROUND: While it is known that some UK Armed Forces (UK AF) personnel and veterans experience physical and mental health problems, the possible future healthcare needs of military veterans are unknown. AIMS: To estimate the number of military personnel who may experience physical and/or psychological health problems associated with their military service. METHODS: Data were obtained via Freedom of Information requests to several sources, including Defence Statistics. Raw data from research studies were also used where available. Data were analysed using meta-analytic methods to determine the rate of physical, mental or comorbid health problems in AF personnel. RESULTS: Musculoskeletal problems were the predominant reason for medical discharge from service. In terms of mental health, meta-analyses estimated that veteran reservists (part-time military members) previously deployed to operational areas had the highest proportion of general health problems (35%), previously deployed veteran regulars (those in full time military employment) and veteran reservists had the highest proportion of post-traumatic stress disorder (9%), and regular personnel with a deployment history had the highest proportion of alcohol problems (14%). Overall, our findings suggest that at least 67515 veterans are likely to suffer from mental and/or physical health problems at some point as a result of their service between 2001 and 2014. CONCLUSIONS: The results of this study highlight that the difficulties personnel may face are largely musculoskeletal or mental health-related. These findings may help with planning the provision of future physical and mental health care and support for those who serve in the UK AF.

Post-traumatic growth in (ex-) military personnel: review and qualitative synthesis.

BACKGROUND: Military service can be a traumatic experience and cause mental health problems in a minority of personnel, such as post-traumatic stress disorder (PTSD), which is linked to negative long-term outcomes. As a result, PTSD has received significant research attention. However, post-traumatic growth (PTG) is a newer construct, with comparatively little known about its presentation and development. AIMS: To qualitatively examine the experience of (PTG) in military and ex-military personnel. METHODS: A qualitative systematic search of electronic databases was conducted, with studies assessed for methodological quality and data analysed using thematic analysis. Nine qualitative studies, carried out between 2011 and 2016, met the inclusion criteria with 195 participants in total, including both military and ex-military personnel. RESULTS: Six themes were identified: appreciation for life, re-evaluating sense of purpose, improvement of personal human traits, bonding and connecting with others, integrating into society, and being proud of heritage and feeling valuable to society. CONCLUSIONS: The results of this review illustrate that military personnel may experience PTG due to deployment-related trauma exposure, and the presentation of PTG in this population is not dissimilar to that of civilians. This study highlights the need for additional research to quantify the long-term psychological impact of PTG and whether a focus on PTG may be helpful in psychological treatment for (ex-) military personnel.

The psychological health of remote area medics in Iraq.

Background: Remote area medics (RAMs) may be at increased risk of mental health difficulties. Aims: To explore the occupational experiences of RAMs to identify stressors and the mental health impact. Methods: Semi-structured interviews were conducted with six RAMs working in Iraq to gather data, which was explored using interpretative phenomenological analysis. Results: Three key themes emerged from the data (i) the experience of being remote, (ii) cultural shock and (iii) social support. A number of key stressors were identified, including loneliness and boredom, associated with being remote, and the loss of professional identity due to the occupational role. Three out of the six participants reported substantial depressive symptoms. A number of positive coping strategies were identified, particularly relationships with other RAMs, via instant messaging forums. Conclusions: RAMs experience a number of particular stressors that could put them at risk of depression. Adaptive coping strategies were identified; in particular, virtual social support. These findings should be of interest to companies which employ RAMs.

Expression quantitative trait loci (eQTLs) in microRNA genes are enriched for schizophrenia and bipolar disorder association signals.

BACKGROUND: Schizophrenia (SZ) and bipolar disorder (BD) have substantial negative impact on the quality of human life. Both, microRNA (miRNA) expression profiling in SZ and BD postmortem brains [and genome-wide association studies (GWAS)] have implicated miRNAs in disease etiology. Here, we aim to determine whether significant GWAS signals observed in the Psychiatric Genetic Consortium (PGC) are enriched for miRNAs. METHOD: A two-stage approach was used to determine whether association signals from PGC affect miRNAs: (i) statistical assessment of enrichment using a Simes test and sum of squares test (SST) and (ii) biological evidence that quantitative trait loci (eQTL) mapping to known miRNA genes affect their expression in an independent sample of 78 postmortem brains from the Stanley Medical Research Institute. RESULTS: A total of 2567 independent single nucleotide polymorphisms (SNPs) (R2 > 0.8) were mapped locally, within 1 Mb, to all known miRNAs (miRBase v. 21). We show robust enrichment for SZ- and BD-related SNPs with miRNAs using Simes (SZ: p ≤ 0.0023, BD: p ≤ 0.038), which remained significant after adjusting for background inflation in SZ (empirical p = 0.018) and approached significance in BD (empirical p = 0.07). At a false discovery rate of 10%, we identified a total of 32 eQTLs to influence miRNA expression; 11 of these overlapped with BD. CONCLUSIONS: Our approach of integrating PGC findings with eQTL results can be used to generate specific hypotheses regarding the role of miRNAs in SZ and BD.

Pitch Memory in Nonmusicians and Musicians: Revealing Functional Differences Using Transcranial Direct Current Stimulation.

For music and language processing, memory for relative pitches is highly important. Functional imaging studies have shown activation of a complex neural system for pitch memory. One region that has been shown to be causally involved in the process for nonmusicians is the supramarginal gyrus (SMG). The present study aims at replicating this finding and at further examining the role of the SMG for pitch memory in musicians. Nonmusicians and musicians received cathodal transcranial direct current stimulation (tDCS) over the left SMG, right SMG, or sham stimulation, while completing a pitch recognition, pitch recall, and visual memory task. Cathodal tDCS over the left SMG led to a significant decrease in performance on both pitch memory tasks in nonmusicians. In musicians, cathodal stimulation over the left SMG had no effect, but stimulation over the right SMG impaired performance on the recognition task only. Furthermore, the results show a more pronounced deterioration effect for longer pitch sequences indicating that the SMG is involved in maintaining higher memory load. No stimulation effect was found in both groups on the visual control task. These findings provide evidence for a causal distinction of the left and right SMG function in musicians and nonmusicians.

Inter- and intra-specific cuticle variation between amphimictic and parthenogenetic species of root-knot nematode (Meloidogyne spp.) as revealed by a bacterial parasite (Pasteuria penetrans).

Specific host-parasite interactions exist between species and strains of plant parasitic root-knot nematodes and the Gram-positive bacterial hyperparasite Pasteuria penetrans. This bacterium produces endospores that adhere to the cuticle of migrating juveniles, germinate and colonise the developing female within roots. Endospore attachment of P. penetrans populations to second-stage juveniles of the root-knot nematode species Meloidogyne incognita and Meloidogyne hapla showed there were interactive differences between bacterial populations and nematode species. Infected females of M. incognita produced a few progeny which were used to establish two nematode lines from single infective juveniles encumbered with either three or 26 endospores. Single juvenile descent lines of each nematode species were produced to test whether cuticle variation was greater within M. hapla lines that reproduce by facultative meiotic parthenogenesis than within lines of M. incognita, which reproduces by obligate parthenogenesis. Assays revealed variability between broods of individual females derived from single second-stage juvenile descent lines of both M. incognita and M. hapla suggesting that progeny derived from a single individual can differ in spore adhesion in both sexual and asexual nematode species. These results suggest that special mechanisms that produced these functional differences in the cuticle surface may have evolved in both sexually and asexually reproducing nematodes as a strategy to circumvent infection by this specialised hyperparasite.

Host-Specific Pathogenicity and Genome Differences between Inbred Strains of Meloidogyne hapla.

Five isolates of M. hapla originating from the Netherlands and California were inbred by sequential transfer of single egg masses to produce six strains. Cytological examination showed that oocytes of these strains underwent meiosis and had n = 16 chromosomes. Strains were tested for ability to infect and to develop on several hosts by in vitro assays. The two strains from California infected tomato roots at a higher rate than those from the Netherlands, but no difference among strains was seen for ability to develop on tomato with or without the resistance gene Mi-1. All strains developed on the common bean cultivar Kentucky Wonder, but strains differed in ability to develop on the nematode-resistant cultivar NemaSnap. Strain-specific differences were also seen in ability to infect and to develop on Solanum bulbocastanum clone SB-22. Strain VW13, derived from nematodes treated with the mutagen EMS, was defective in ability to infect tomato and potato roots in vitro. Comparison of DNA using AFLP markers showed an average of 4% of the bands were polymorphic across the six strains, but no correlation was observed between the geographical origin or virulence and DNA polymorphism pattern.

Fine mapping of the nematode resistance gene Mi-3 in Solanum peruvianum and construction of a S. lycopersicum DNA contig spanning the locus.

Currently, the only genetic resistance against root-knot nematodes in the cultivated tomato Solanum lycopersicum (Lycopersicon esculentum) is due to the gene Mi-1. Another resistance gene, Mi-3, identified in the related wild species Solanum peruvianum (Lycopersicon peruvianum) confers resistance to nematodes that are virulent on tomato lines that carry Mi-1, and is effective at temperatures at which Mi-1 is not effective (above 30 degrees C). Two S. peruvianum populations segregating for Mi-3 were used to develop a high-resolution map of the Mi-3 region of chromosome 12. S. lycopersicum BACs carrying flanking markers were identified and used to construct a contig spanning the Mi-3 region. Markers generated from BAC-end sequences were mapped in S. peruvianum plants in which recombination events had occurred near Mi-3. Comparison of the S. peruvianum genetic map with the physical map of S. lycopersicum indicated that marker order is conserved between S. lycopersicum and S. peruvianum. The 600 kb contig between Mi-3-flanking markers TG180 and NR18 corresponds to a genetic distance of about 7.2 cM in S. peruvianum. We have identified a marker that completely cosegregates with Mi-3, as well as flanking markers within 0.25 cM of the gene. These markers can be used to introduce Mi-3 into cultivated tomato, either by conventional breeding or cloning strategies.

Interspecies exchange mutagenesis of the first epidermal growth factor-like domain of human factor VII.

The first epidermal growth factor-like (EGF1) domain of human factor VII (FVII) is essential for binding to tissue factor (TF). We hypothesized that the previously observed increased coagulant activity of rabbit plasma (i.e. FVII) with human TF might be explained by the five non-conserved amino acids in the rabbit vs. the human FVII EGF1 domain. Accordingly, we 'rabbitized' the human FVII EGF1 domain either by exchanging the entire EGF1 domain creating human FVII(rabEGF1) or by the single amino acid substitutions S53N, K62E, P74A, A75D and T83K. After transient expression in HEK293 cells, the recombinant FVII (rFVII) mutant proteins were analyzed for biological activity and binding affinity to human TF by competitive enzyme-linked immunosorbent assay (ELISA). Biological activity of the unpurified rFVII mutant proteins was either depressed or statistically unchanged vs. rFVII(WT). However, three of six rFVII mutant proteins had increased affinity for human TF in the rank order rFVII(rabEGF1) (3.3-fold) > rFVII(K62E) (2.9-fold) > rFVII(A75D) (1.7-fold). The mutant protein rFVII(K62E) was then permanently expressed and purified. Fully activated, purified rFVIIa(K62E) had a twofold greater clotting activity and 2.8-fold greater direct FVIIa amidolytic activity when compared with rFVIIa(WT). Quantitation of the affinity of TF binding by surface plasmon resonance indicated that the KD of purified rFVII(K62E) for human soluble TF (sTF) was 1.5 nM compared with 7.5 nM for rFVII(WT), i.e. fivefold greater affinity. We conclude that substitution of selected amino acid residues of the FVII EGF1 domain facilitated the creation of human rFVII chimeric proteins with both enhanced biological activity and increased affinity for TF.

The nematode-resistance gene, Mi-1, is associated with an inverted chromosomal segment in susceptible compared to resistant tomato.

The gene Mi-1 confers effective resistance in tomato ( Lycopersicon esculentum) against root-knot nematodes and some isolates of potato aphid. This locus was introgressed from L. peruvianum into the corresponding region on chromosome 6 in tomato. In nematode-resistant tomato, Mi-1 and six homologs are grouped into two clusters separated by 300 kb. Analysis of BAC clones revealed that the Mi-1 locus from susceptible tomato carried the same number and distribution of Mi-1 homologs, as did the resistant locus. Molecular markers flanking the resistant and susceptible loci were in the same relative orientation, but markers between the two clusters were in an inverse orientation. The simplest explanation for these observations is that there is an inversion between the two clusters of homologs when comparing the Mi-1 loci from L. esculentum and L. peruvianum. Such an inversion may explain previous observations of severe recombination suppression in the region. Two Mi-1 homologs identified from the BAC library derived from susceptible tomato are not linked to the chromosome 6 locus, but map to chromosome 5 in regions known to contain resistance gene loci in other solanaceous species.

Discrimination of six pratylenchus species using PCR and species-specific primers.

A PCR-based assay for identification of six species of Pratylenchus common in California is described. In this assay, five forward species-specific primers were designed from the internal variable portion of the D3 expansion region of the 26S rDNA and were each used with a single, common reverse primer. The optimized species-specific primers produced unique amplicons from their respective target and did not amplify DNA from other Pratylenchus species. With this assay we were able to identify single females to species level. This method obviates the need for subsequent RFLP or sequence analysis of the PCR product and can be used as a rapid diagnostic tool in epidemiological and management studies.

Plain abdominal radiographs in acute medical emergencies: an abused investigation?

Plain abdominal radiographs are commonly requested for acute medical emergencies on patients with non-specific abdominal symptoms and signs. In this study 131 plain abdominal radiographs performed on the day of admission were prospectively analysed. In only 16 cases (12%) the reasons for requests conformed to the recommended guidelines by the Royal College of Radiologists. The reason for the request was stated in the case notes in only three cases. In 62 cases (47%), there was no comment made on the film by the requesting clinician. There was a discrepancy in the interpretation of the radiograph between the clinician and the radiologist in 31 cases (24%). The clinical management was influenced by plain abdominal radiographs in only nine cases (7%). The majority of plain abdominal radiographs requested on acute medical emergencies is inappropriate. There is a need to ensure guidelines are followed to prevent unnecessary exposure of patients to radiation as well as preventing expenditure on irrelevant investigations.

Evidence for a role of the N terminus and leucine-rich repeat region of the Mi gene product in regulation of localized cell death.

The tomato Mi gene confers resistance against root-knot nematodes and potato aphids. Chimeric constructs of the functional gene, Mi-1. 2, with a homolog, Mi-1.1, were produced, and their phenotypes were examined in Agrobacterium rhizogenes-transformed roots. Exchange of the leucine-rich repeat (LRR) region of Mi-1.1 into Mi-1.2 resulted in the loss of ability to confer nematode resistance, as did substitution of a 6-amino acid sequence from the Mi-1.1 LRR into Mi-1.2. Introduction of the Mi-1.2 LRR-encoding region into Mi-1.1 resulted in a lethal phenotype, as did substitution of the fragment encoding the N-terminal 161 amino acids of Mi-1.1 into Mi-1.2. Transient expression of the latter two chimeric constructs in Nicotiana benthamiana leaves produced localized cell death. The cell death caused by the N-terminal exchange was suppressed by coinfiltration with a construct expressing the N-terminal 161 amino acids of Mi-1.2. The phenotypes of these and other constructs indicate that the LRR region of Mi-1.2 has a role in signaling localized cell death and that the N-terminal 161 amino acids have a role in regulating this death.

Plasmid-mediated expression of the UmuDC mutagenesis proteins in an Escherichia coli strain engineered for human cytochrome P450 1A2-catalyzed activation of aromatic amines.

The mutagenic actions of many chemicals depend on the activities of bacterial "mutagenesis proteins", which allow replicative bypass of DNA lesions. Genes encoding these proteins occur on bacterial chromosomes and plasmids, often in the form of an operon (such as umuDC or mucAB) encoding two proteins. Many bacterial strains used in mutagenicity testing carry mutagenesis protein genes borne on plasmids, such as pKM101. Our objective was to introduce mutagenesis protein function into Escherichia coli strain DJ4309. This strain expresses recombinant human cytochrome P450 1A2 and NADPH-P450 reductase and carries out the metabolic conversion of aromatic and heterocyclic amines into DNA-reactive mutagens. We discovered that many mutagenesis-protein plasmids severely inhibit the response of strain DJ4309 to 2-amino-3,4-dimethylimid-azo[4,5-f]quinoline (MeIQ), a typical heterocyclic amine mutagen. Among many plasmids examined, one, pGY8294, a pSC101 derivative carrying the umuDC operon, did not inhibit MeIQ mutagenesis. Strain DJ4309 pGY8294 expresses active mutagenesis proteins, as shown by its response to mutagens such as 1-nitropyrene and 4-nitroquinoline 1-oxide (4-NQO), and is as sensitive as the parent strain DJ4309 to P450-dependent mutagens, such as MeIQ and 1-aminopyrene.

Plant nematode resistance genes.

Root-knot and cyst nematodes cause severe damage to crops throughout the world. Genes conferring resistance against nematodes have been identified in many plant species and several of these have been, or soon will be, cloned. Nematode biotypes that can infect resistant plants have been identified. Investigation of cloned resistance genes and of virulent nematodes is likely to lead to improved host resistance.